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1Running Head: ART THERAPY AND HOMELESSNESS

Effects of Art Therapy on Individuals Who are Homeless

By Christina Meskil

Western Washington University; Human Services Department

HSP 385 – Applied Research Methods


Abstract

This research proposal seeks to answer the question “What is the effect of art therapy on

individuals who are homeless?” There will be a brief overview of some of the psychological

implications of homelessness as well as an overview of the purposes of art therapy. This proposal

contains a summary of similar studies done to test the effectiveness of art therapy programs with

various populations, as well as a proposal for a new study to be conducted specifically with

homeless individuals in the United States.

Introduction

The United States is one of the wealthiest nations in the world with a gross domestic

product of over 15 trillion dollars according to the World Bank (2013), and yet, according to the

National Alliance to End Homelessness, there are over 633,782 people experiencing

homelessness in America (2013). Experiences of poverty and homelessness can have profound

impacts on people’s sense of sense of identity and self-esteem. It is presented that employment

quality of life, mental health, status, social networks, and personal identity; this can be attributed

to our society’s tendency to define people by their occupation (Williams & Stickley, 2011).

Researchers Williams and Stickley conducted a series of interviews with people

experiencing homelessness. Common themes in these interviews were expressed feelings of

rejection and stigma. Participants reported that homeless makes them feel lost and like they do

not know who they are anymore. They shared that they had frequently experienced harassment

from the general public. One man, John, describes this harassment “...people take offence as you

look dirty and just decide to beat you up because you are homeless which happens quite often


now...” This rejection consequently leads to a negative perception of self and experiences of

stigmatization (2011).

According to the American Art Therapy Association, art therapy is a therapeutic process

in which a professional utilizes art to engage clients in a creative process that helps them explore

their feelings, foster self-awareness, manage behavior and addictions, develop social skills,

reduce anxiety and improve self-esteem (2013).

This paper is proposing a study to be done around the benefits of conducting art therapy

programs within the homeless population. This proposed study is important because it may

create a way for people experiencing homelessness to recover from their feelings of negative

self-perception and stigmatization.

Review of Literature

What we see from the large body of research done thus far in the area of art therapy is

that art therapy among vulnerable populations has a significant positive impact on mood,

attitude, and self-esteem (Thomas et al., 2011). We see this in populations such as the elderly

(Kim, 2013) and troubled youth (Kelly, 2010). What is missing, and indeed what this proposal is

recommending be explored further, is how art therapy can be implemented in homeless adult

populations. We do find one study done in which the focus of an art therapy program is the

homeless adult population; however, the study itself has limitations which will be discussed at

length (Thomas et al.).

Australian psychotherapist and art therapy expert Jo Kelly put forth an article discussing

the efficacy and importance art therapy. “Art therapy is a modality of psychotherapy that uses the

visual creative process for healing,” says Kelly (2010, pg. 255). Kelly also put forth that art is a


particularly useful asset when looking at populations with no or limited language capabilities to

describe their experiences. As we have grown in our understanding of the brain, we learn that

images themselves greatly influence our thoughts, feelings, and wellbeing (Hass-Cohen & Carr,

2008). Of art therapy, Kelly says this:

The uniqueness of art therapy as a modality can be seen by its ability to move between

interior and exterior worlds, between the pictorial and verbal. As an experiential activity,

the sensory nature of working with art materials can provoke behavioral changes and

prompt stimulation of memory. The art becomes the evidence of the experience. It can be

reflected upon, destroyed, remarked upon, retained and reviewed. (pg. 257)

Through this, Kelly explains the inherent value in art therapy, and good cause to consider

pursuing further research.

Kim (2013) collected data from aging Korean-Americans to examine some of the benefits

of art therapy. Many older adults consider the end stages of life to be ones of hopelessness,

dependence, waiting for death, losing family members, sickness, and boredom (Hooyman &

Kiyak, 2002), and Kim undertook a study to see how the use of art therapy could mitigate some

of these end of life negative thoughts. The study utilized a pre-test post-test design and the data

was collected from 50 Korean-Americans from two adult day health care programs (ADHCP),

one in New Jersey and the other in New York. Participants were selected using a mini mental

status exam (MMSE). Clients who scored at least a 25 out of 30 (indicating high cognitive

functioning), and who had not participated in art therapy before were invited to participate in the

study. Participants were randomly sorted into either the intervention group or the control group.

Both groups were given three tests before and after the intervention received their art therapy

intervention: the Positive and Negative Affect Schedule (PANAS), the State-Trait Anxiety


Inventory (STAI), and the Rosenberg Self-Esteem Scale (RSES). This methodology for testing

the efficacy of an art therapy program and its impact on participants seems effective and may be

valuable to duplicate in further research. The outcomes of this particular study showed that aging

Korean-Americans who participated in art therapy showed higher self esteem, reduced anxiety,

reduced negative emotions, and promotes better quality of life (Kim).

While the proposed study will focus largely on homeless adults, the “Hunger and

Homelessness Survey” put out by the United States Conference of Mayors shows that

approximately a quarter of the homeless population consists of families. The YWCA did a study

of a homeless youths’ art program. The authors echo Kelly (2010) in advocating art as an ideal

mode of expression for those with limited ability to express themselves. Results show that

children in the art program experience belonging, success and creativity (Shepard & Booth,

2009).

In the Australian study of art therapy and the homeless population (Thomas, et. al, 2011)

we see what potential this topic has for being fruitful. Thomas, Gray, McGinty and Ebringer

conducted a small scale art therapy study within a homeless population. The majority of research

done was qualitative. Unfortunately, this particular study has some short comings. The

population size of this study is very small, and there are no pre or post study interviews. The lack

of pre or post study interviews is significant because it calls into question whether change had

begun prior to the art therapy, and if the change was sustained once the test was complete. The

small scale of the study is inadequate to draw reliable conclusions from. The study does yield,

however, some structure for how future research might be conducted. Thomas, Gray, McGinty

and Ebringer report that three major themes emerged from their study, these themes being the

beginning of engagement and participation stage, benefits to clients, and recognition from the


community. As we look to future research, these areas are ones to pay special attention to.

Finally, this study also shows some of the potential outcomes for clients in art therapy programs.

Some of the outcomes seen in this Australian study show that clients experienced the benefits of

self-discovery, decision making, diversion from alcohol and other addictions, and relief from

mental health issues. This should provide cause as well as home when it comes to future

research.

Art therapy is a proven successful technique for elevating self-esteem, reducing anxiety,

reducing negative emotions, and promoting better quality of life (Kim, 2013). It also promotes

belonging, success, creativity, (Shepard & Booth, 2009) and gives a voice to the voiceless

(Kelly, 2010). In homeless adults, art therapy has the potential to develop self-discovery,

decision making, diversion from alcohol and other addictions, and relief from mental health

issues (Thomas, et. al, 2011). Further research is needed to explore this topic in depth.

Methods

Research Design

Researcher will utilize a longitudinal trend design for this study. This will allow for the

observation of how art therapy affects individuals who are homeless over time. We will do this

by administering the same test twice to our participants over a 6 week period. The tests

administered to participants will give quantitative results (Marlow, 2011) representing affect

(Watson & Clark, 1999), anxiety (Speilberger, Gorsuch, Lushene, Vagg & Jacobs, 1983), and

self-esteem (Blascovich & Tomaka, 1993). This method was modeled after a similar study done

to gauge the effectiveness of art therapy programs among other populations (Kim, 2013).

Participants


To answer the question “What is the effect of art therapy on individuals who are

homeless?” our team will compile a list of every homeless drop-in center and day health center

in the United States. From this list we will randomly select 100 centers to participate in the

study. Fifty of these centers will be given the opportunity to participate in the art therapy session;

this will be called the therapy group. The other 50 centers will not participate in art therapy

sessions, but will be observed and referred to as the control group.

Instrument

The art therapy will be offered to the therapy group every day for six weeks. Participation

will be voluntary. Participants will be able to withdraw or join or rejoin at any point in the

process, however observers will make note of how many sessions each individual participated in.

Prior to the therapy group receiving treatment, both the therapy and the control group will

be asked to take 3 tests: the Positive and Negative Affect Schedule extended form (PANAS-X),

the State-Trait Anxiety Inventory (STAI), and the Rosenberg Self-Esteem Scale (RSES). The

PANAS-X (Appendix A) presents participants with 60 words describing feelings or emotions

and asks them to score each word on a scale of 1-5 of how often they have felt the feeling or

emotion in the past week. The data is observed by comparing how participant ranked positive

emotions versus negative emotions (Watson & Clark, 1999). The STAI (Appendix B) measures

levels of depression and anxiety asking participants to rate 40 statements on a scale of 1-4 in

terms of how often that statement applies to them (1 being almost never, 4 being almost always).

Some examples of these statements would be “I am worried” and “I worry too much about

something that doesn’t really matter” (Speilberger, Gorsuch, Lushene, Vagg & Jacobs, 1983).

Finally, the RSES (Appendix C) assesses self-esteem using a ten item scale. 5 of the items are


positive statements, 5 are negative and participants are asked to rate them on a 1-4 scale of

strongly agree to strongly disagree (Blascovich & Tomaka, 1993).

Data Collection

All participants, both in the control group and the therapy group will be given an

informed consent form (Appendix D) which will be explained to them before they are given the

choice to sign and participate or not. These 3 tests will be administered to both the therapy group

and the control group prior to art therapy course, and then again after the therapy group has

undergone the therapy. There will be no names included on the tests, and completed tests will be

stored in a secure location.

Data Analysis

Tests will be gathered by researchers and coded according to which group (control or

therapy) the individual is in, and whether the test was taken before or after the art therapy

treatment had been conducted. The PANAS-X will be evaluated using Appendix E to compare

the affect of the therapy group and the control group before and after the art therapy treatment

(Watson & Clark, 1999). The STAI will use Appendix F to compare levels of anxiety of the

therapy group and the control group before and after the art therapy treatment (Speilberger,

Gorsuch, Lushene, Vagg & Jacobs, 1983). Finally, the RSES will use Appendix G to compare

the levels of self-esteem of the therapy group and the control group before and after the art

therapy treatment (Blascovich & Tomaka, 1993).

Feasibility


In this proposed study, limitations may arise as we cannot ethically and do not desire to

force any one to participate against their will; We will also not be able to obtain understanding of

why individuals chose not to participate or if that group of non-participants would have had a

different experience with the art therapy treatment.

Because this proposed study would be conducted by individuals who are hoping to

promote art therapy in the homeless population, there is already a bias toward the subject matter

of this study. In order to obtain accurate, unbiased data it will be important for the researchers

who are collecting data and conducting interviews to avoid using language that will prompt the

participants to affirm art therapy or discouraging them from speaking freely against art therapy.

Another prospective limitation may be that researchers may be unaware of while

conducting this study, is that some participants may be struggling with mental illness. National

Coalition for the Homeless (2009) states that, 20 to 25% of the homeless population in the

United States suffers from some form of severe mental illness. This needs to be a consideration

when administering informed consent and discerning whether participants are able to give

informed consent. It is also important to tread carefully when it comes to the subject matter of

the art therapy and whenever possible to minimize risk by avoiding possibly inflammatory

topics.

This research may be used by a variety of different organizations seeking alternative

methods for providing support and reprieve for individuals dealing with homelessness.


References

American Art Therapy Association. (July, 2013). What is art therapy?. Retrieved from

http://www.americanarttherapyassociation.org/upload/whatisarttherapy.pdf

Blascovich, J., & Tomaka, J. (1993). Measures of personality and social psychological attitudes.

(3rd ed., pp. 115-160). Ann Arbor, MI: Institute for Social Research.

Hass-Cohen, N., & Carr, R. (2008). Art therapy and clinical neuroscience. London: Jessica

Kingsley.

Hooyman, N. R., & Kiyak, H. I. (2002). Social gerontology: A multidisciplinary perspective.

(6th ed.). Boston, MA: Allyn and Bacon.

Kelly, J. (2010). What is art therapy and how do we know it works? An Australian perspective

on the need for more research. International Journal of Interdisciplinary Studies, 5(5),

255-259.

Kim, S. (2013). A randomized, controlled study of the effects of art therapy on older Korean-

Americans’ healthy aging. Arts in Psychotherapy, 40(1), 158-164. doi:

10.1016/j.aip.2012.11.00

Marlow, C. R. (2011). Research methods for generalist social work. (5th ed., p. 154). Belmont,

CA: Brooks/Cole, Cengage Learning.

National Coalition for the Homeless, (2009). Mental illness and homelessness. Retrieved from

website: http://www.nationalhomeless.org/factsheets/Mental_Illness.pdf

Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton

University Press.

http://www.nationalhomeless.org/factsheets/Mental_Illness.pdf


Shepard, J., & Booth, D. (2009). Heart to heart art: Empowering homeless children and

youth. Reclaiming Children & Youth, 18(1), 12-15.

Speilberger, C. D. (1977). State-trait anxiety inventory for adults. Redwood City, CA: Mind

Garden. Retrieved from: www.mindgarden.com/products/staisad.htm

Speilberger, C. D., Gorsuch, R. L., Lushene, R., Vagg, P. R., & Jacobs, G. A. (1983). Manual for

the state-trait anxiety inventory. Palo Alto, CA: Consulting Psychologists Press.

The National Alliance to End Homelessness, (2013). The state of homelessness in America 2013.

Retrieved from website: http://www.endhomelessness.org/library/entry/the-state-of-

homelessness-2013

The United States Conference of Mayors, (2011). Hunger and homelessness survey. Retrieved

from website: http://usmayors.org/pressreleases/uploads/2011-hhreport.pdf

The World Bank, (2013). Gdp. Retrieved from website:

http://data.worldbank.org/indicator/NY.GDP.MKTP.CD

Thomas, Y., Gray, M., McGinty, S., & Ebringer, S. (2011). Homeless adults engagement in art:

First steps towards identity, recovery and social inclusion. Australian Occupational

Therapy Journal, 58(6), 429-436. doi: 10.1111/j.1440-1630.2011.00977.

Watson, D., & Clark, L. A. (1999). Manual for the positive and negative affect schedule:

Expanded form. University of Illinois, Retrieved from

http://www2.psychology.uiowa.edu/faculty/clark/panas-x.pdf

http://www2.psychology.uiowa.edu/faculty/clark/panas-x.pdf

http://usmayors.org/pressreleases/uploads/2011-hhreport.pdf


Williams, S., & Stickley, T. (2011). Stories from the streets: People’s experiences of

homelessness. Journal of Psychiatric and Mental Health Nursing, 18(5), 432-439. doi:

10.1111/j.1365-2850.2010.01676.x


Appendix A

PANAS-X

This scale consists of a number of words and phrases that describe different feelings and emotions. Read each item and then mark the appropriate answer in the space next to that word. Indicate to what extent you have felt this way during the past few weeks. Use the following scale to record your answers:

1-very slightly or not at all; 2-a little; 3-moderately; 4-quite a bit; 5-extremely

______ cheerful ______ sad ______ active ______ angry at self

______ disgusted ______ calm ______ guilty ______ enthusiastic

______ attentive ______ afraid ______ joyful ______ downhearted

______ bashful ______ tired ______ nervous ______ sheepish

______ sluggish ______ amazed ______ lonely ______ distressed

______ daring ______ shaky ______ sleepy ______ blameworthy

______ surprised ______ happy ______ excited ______ determined

______ strong ______ timid ______ hostile ______ frightened

______ scornful ______ alone ______ proud ______ astonished

______ relaxed ______ alert ______ jittery ______ interested

______ irritable ______ upset ______ lively ______ loathing

______ delighted ______ angry ______ ashamed ______ confident

______ inspired ______ bold ______ at ease ______ energetic

______ fearless ______ blue ______ scared ______ concentrating

______ disgusted ______ shy ______ drowsy ______ dissatisfied with self with self

(Watson & Clark, 1999)


Appendix B


(Speilberger, 1977)


Appendix C

Rosenberg Self-Esteem Scale

Instructions: Below is a list of statements dealing with your general feelings about yourself. If you strongly agree, circle SA. If you agree with the statement, circle A. If you disagree, circle D. If you strongly disagree, circle SD.

1. On the whole, I am satisfied with myself. SA A D SD

2.* At times, I think I am no good at all. SA A D SD

3. I feel that I have a number of good qualities. SA A D SD

4. I am able to do things as well as most other people. SA A D SD

5.* I feel I do not have much to be proud of. SA A D SD

6.* I certainly feel useless at times. SA A D SD

7. I feel that I’m a person of worth, at least on an equal plane with others. SA A D SD

8.* I wish I could have more respect for myself. SA A D SD

9.* All in all, I am inclined to feel that I am a failure. SA A D SD

10. I take a positive attitude toward myself. SA A D SD

(Rosenberg, 1965)


Appendix D

Effects of Art Therapy on Homeless AdultConsent Form

Principal Investigator:Christina MeskilStudent, Human Services Dept.Western Washington University(253) 279-9269

Description:I am interested in the effect of art therapy within the homeless adult population. In this study you will be placed in one of two groups, one of which participate in daily art therapy sessions for six weeks, the other will not. Regardless of which group you are in, once before and once after the six week period we will give you a series of psychological

Confidentiality:Your name will not be attached to your test results or interview responses. Your name and any other identifiers will be kept in a locked file that is only accessible to me or my research associates. Any information from this study that is published will not identify you by name.

Benefits:This study may provide you with an opportunity to participate in a potentially beneficial experience with art therapy. Results of this study may benefit other homeless adults by providing information to social workers, case managers, and other professionals in the field about how to create programing and treatment that is effective for homeless adults.

Risk:Participating in the art therapy sessions and discussion of feelings may make you feel sad or uncomfortable. However, there are no other known risks to you.

Contact People: If you have any questions you may contact the principal investigator at the phone number listed above. If you have any question about your rights as a research subject, please contact the Office of the Vice Provost for Research at Western Washington University at (360-650-2884).

Voluntary Nature of Participation:Your participation in this study is voluntary. If you don’t wish to participate, or would like to end your participation in this study, there will be no penalty or loss of benefits to which you are otherwise entitled. In other words, you are free to make your own choice about being in this study or not, and may quit at any time without penalty.

Signature:Your signature on this consent form indicates that you fully understand the above study, what’s being asked of you in this study, and that you are signing this voluntarily. If you have any questions about this study, please feel free to ask them now or at any time throughout the study.

Signature_________________________ Date___________

A copy of this consent form is available for you to keep.

(Marlow, 2011)


Appendix E

Evaluating the PANAS-X

General Dimension Scales

Negative Affect (10) afraid, scared, nervous, jittery, irritable, hostile, guilty, ashamed, upset, distressed

Positive Affect (10) active, alert, attentive, determined, enthusiastic, excited, inspired, interested, proud, strong

Basic Negative Emotion Scales

Fear (6) afraid, scared, frightened, nervous, jittery, shaky

Hostility (6) angry, hostile, irritable, scornful, disgusted, loathing

Guilt (6) guilty, ashamed, blameworthy, angry at self, disgusted with self, dissatisfied with self

Sadness (5) sad, blue, downhearted, alone, lonely

Basic Positive Emotion Scales

Joviality (8) happy, joyful, delighted, cheerful, excited, enthusiastic, lively, energetic

Self-Assurance (6) proud, strong, confident, bold, daring, fearless

Attentiveness (4) alert, attentive, concentrating, determined

Other Affective States

Shyness (4) shy, bashful, sheepish, timid

Fatigue (4) sleepy, tired, sluggish, drowsy

Serenity (3) calm, relaxed, at ease

Surprise (3) amazed, surprised, astonished

(Watson & Clark, 1999)


Appendix FEvaluating the STAI

(Speilberger, 1977)


Appendix G

Scoring the RSES

Scoring: SA=3, A=2, D=1, SD=0. Items with an asterisk are reverse scored, that is, SA=0, A=1,

D=2, SD=3. Sum the scores for the 10 items. The higher the score, the higher the self esteem.

(Rosenberg, 1965)

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